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First Appropriate Use Criteria for Peripheral Artery Intervention

For the first time, appropriate use criteria (AUC) have been issued to provide guidance as to which interventions and devices to use — but also which should be avoided — in the management of patients with peripheral artery disease (PAD).

Peripheral artery intervention has been the subject of several single-society guidance efforts, but this is the first multisociety effort on the topic.

“The large group of professionals with individual skill sets we had collaborating on this document — vascular surgeons, cardiologists, interventional cardiologists, interventional radiologists, and medical doctors not doing procedures but taking care of these patients — really sends a message about how we share the care of these patients and how complex their care can be,” said Steven Bailey, MD, chair of the Peripheral Artery Intervention Writing Group in an interview with theheart.org | Medscape Cardiology. Bailey is program director, interventional cardiology, and professor of medicine and radiology at the University of Texas Health Science Center at San Antonio.

The authors hope their AUC effort will not just be helpful to interventionalists wanting to keep abreast of a fast-moving field, but that it will also inform clinicians who may refer patients for revascularization.

The new guidance, published online December 17 in the Journal of the American College of Cardiology, was a joint collaboration by the American College of Cardiology (ACC), American Heart Association, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, and Society for Vascular Medicine, along with several ACC councils.

In scoring the many clinical scenarios covered — which Bailey stressed is not a comprehensive list, but rather a limited set of scenarios and patient presentations judged to be “most common or most important to discuss” — the working group was asked to assess whether the use of a specific intervention for each clinical indication should be categorized as Appropriate, May Be Appropriate, or Rarely Appropriate.

“Ideally, this document will serve as an educational and quality improvement tool for addressing Rarely Appropriate revascularizations either performed or referred by individual clinicians,” the AUC authors write.

“Experience with prior AUC topics has shown that physician engagement in quality improvement programs, plus tracking and benchmarking of ordering behavior, has reduced the percentage of Rarely Appropriate interventions.”

They noted that just as a rating of Appropriate “should not be misconstrued as a mandate to perform a specific intervention in every patient that meets the indications described herein,” a Rarely Appropriate designation is not a charge to never use a device or intervention.

“Appropriate use criteria are designed to provide information regarding population care, not necessarily individual patient care, and that’s because every patient is so different in terms of their risk factors and their clinical presentation, and particularly for peripheral vascular disease, their anatomy, so it’s difficult to say that this is exactly what should happen or what shouldn’t happen,” said Bailey.

In many cases, he explained, the classification is used to simply reflect a lack of data to support use and a call for more research. “Where we don’t have a lot of data we want the community, whether that’s the physicians or industry or patients, to be aware that these are areas we want to look at more carefully, and hopefully that will drive individuals to begin to answer some of these questions and provide data to have thoughtful and appropriate — no pun intended — utilization of those devices.”

“To use this document to make statements about, ‘Well, you should do this or shouldn’t do that,’ as opposed to saying, ‘If you care for 50 or 100 patients, then more often than not this is what you should be doing,’ is really where this guideline should help,” said Bailey.

In the Rarely Appropriate category was the use of atherectomy to treat discrete or diffuse disease in the iliac artery.

Bailey explained the designation: “This is an area that is truly an uncommon clinical scenario and area where based on vessel size, it would probably be rarely appropriate to choose atherectomy over balloon angioplasty or stenting, but we probably aren’t ever going to have enough cases to study this either.”

Another Rarely Appropriate designation was given to the use of endovascular or surgical treatment in a patient with intermittent claudication when no prior guideline-directed medical therapy has been given.

“That’s just sending the message that if you haven’t engaged in treating the patient medically in the optimal fashion, you really want to think about whether you should do revascularization,” said Bailey.

“But again, in any given patient, there may be times when it’s the right thing to do, but it probably shouldn’t be what you usually do.”

The writing group’s intention is to continually adjust and update this AUC document to reflect new information as it becomes available.

“This is just the first iteration of what is meant to be a living document. We’ve addressed here those areas that we thought were important, but as we learn more, we expect that there will be revisions and we look forward to this really becoming something that the community is engaged in as it goes forward,” said Bailey.

Bailey has reported receiving research funding from Boston Scientific for his participation on a data and safety monitoring board. 

J Am Coll Cardiol. Published online December 17, 2018. Full text

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